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War in Nagorno-Karabakh highlights the vulnerability of displaced populations to COVID-19
  1. Arin A Balalian1,
  2. Alique Berberian2,
  3. Araz Chiloyan3,
  4. Maral DerSarkissian4,
  5. Vahe Khachadourian5,6,
  6. Eva Laura Siegel1,
  7. Christina Mehranbod1,
  8. Vaneh Hovsepian7,
  9. Richard J Deckelbaum8,
  10. Pam Factor-Litvak1,
  11. Sharon Daniel9,
  12. Shira Shafir10,
  13. Alina Dorian10,
  14. Kim Hekimian8
  15. Public Health Working Group for Armenia
    1. 1 Department of Epidemiology, Columbia University, New York, New York, USA
    2. 2 Department of Environmental Health Sciences, University of California Los Angeles, Los Angeles, California, USA
    3. 3 Ministry of Health, Yerevan, Armenia
    4. 4 Department of Epidemiology, University of California Los Angeles, Los Angeles, California, USA
    5. 5 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
    6. 6 Gerald and Patricia Turpanjian School of Public Health, American University of Armenia, Yerevan, Armenia
    7. 7 School of Nursing, Columbia University, New York, New York, USA
    8. 8 Institute of Human Nutrition, Columbia University, New York, New York, USA
    9. 9 Department of Public Health, Ben-Gurion University of the Negev, Beer-Sheva, Israel
    10. 10 Department of Community Health Sciences, University of California Los Angeles, Los Angeles, California, USA
    1. Correspondence to Dr Arin A Balalian, Columbia University, New York, USA; aa3794{at}

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    Conflict, war and the resultant displacement of populations increase risk for infectious disease transmission. Forced migration, loss of safe shelter, loss of livelihood and interrupted access to clean water, electricity and healthcare all lead to increases in epidemic risk. Refugees and displaced people are uniquely vulnerable to COVID-19. The chaos of war and its aftermath override the population health education messages to wear a mask, socially distance and wash hands frequently.

    Risk of COVID-19 transmission is heightened for people living in densely populated community spaces and overcrowded shelters, particularly for those with inadequate access to clean running water, soap and appropriate sanitation and hygiene facilities. Such circumstances make it challenging to physically distance and maintain proper hand hygiene. Overwhelmed healthcare systems and fragile capacities for social services further contributes to group-specific vulnerabilities of refugees and displaced people. World Health Organization (WHO) and the United Nations High Commissioner for Refugees (UNHCR) have recognised the disproportionate impact of the pandemic on these communities and the need to protect them.1 2 We, the Public Health Working Group for Armenia, echo the call previously made by Kluge et al 3 for an inclusive approach in guiding the global response to the COVID-19 pandemic, emphasising the principle of leaving no one behind. We are particularly concerned about the postconflict setting in the Nagorno-Karabakh Region and the recently displaced Armenian population who have relocated to the Republic of Armenia.

    In November 2020, the governments of Azerbaijan, Russia and Armenia signed a ceasefire agreement which brought an end to a 6-week long war between Azerbaijan and Armenia over the disputed Nagorno-Karabakh region, an enclave historically populated by indigenous ethnic Armenians (online supplemental file 1). A recent re-escalation of the decades-long conflict, despite the United Nations Secretary General’s call for a global ceasefire during the pandemic4 …

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    • Correction notice This article has been corrected since it first published. Tsoline Kojaoghlanian is now included in the list of collaborators of the 'Public Health Working Group for Armenia.'

    • Collaborators Public Health Working Group for Armenia: The other members are: Tamar Kabakian-Khasholian (Faculty of Health Sciences, American University of Beirut), Elena Sagayan (Kaiser Permanente Obstetrics And Gynecology, 3000 Las Positas Rd, Livermore, CA, 94551), Lorky Libaridian (Department of Internal Medicine, Harvard Medical School, Boston, Massachusetts, US.), Shant Shekherdimian (Division of Pediatric Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California, US.), Naira Setrakian (Children’s Oncology Group, 800 Royal Oaks Drive, Suite 210 Monrovia, CA 91016), Alicia Demirjian (Evelina London Children's Hospital, London, UK); Talar Habeshian (Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, Pasadena, CA), Lara Rostomian (Harvard T.H. Chan School of Public Health, Department of Epidemiology, 677 Huntington Ave, Boston, MA 02115, USA), Michael Abassian (School of Public Health, University of California Berkley, 2121 Berkeley Way, Room 5302, Berkeley, CA), Christine Mavilian (Department of Integrative Biology and Physiology, Graduate Program in Physiological Science, University of California, Los Angeles, Los Angeles, CA), and

      Tsoline Kojaoghlanian (Maimonides Children’s Hospital, Brooklyn, New York, NY, USA).

    • Contributors Conceptualisation, ArB and KH.; writing—original draft preparation, ArB and AlB.; writing—review and editing, ArB and AlB, AC, MD, VK, ELS, CM, VH, RJD, PF-M, SD, SS, AD, KH; visualisation, AC; supervision, KH. All the members of Public Health working group for Armenia have read and agreed to the published version of the manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

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    • Competing interests None declared.

    • Provenance and peer review Not commissioned; internally peer reviewed.

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